Basic Information
| Provider Information | |||||||||
| NPI: | 1154537058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRISCO | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | MD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9602 | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913469602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188375691 | ||||||||
| FaxNumber: | 8187924793 | ||||||||
| Practice Location | |||||||||
| Address1: | 11333 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183659531 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 04/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 236893 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 236893 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | A108810 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A1088100 | 05 | CA | MEDICAID | GR0100430 | 01 | CA | GROUP MEDICAL | OTHER | 1902846306 | 01 | CA | GROUP NPI | OTHER | W18762 | 01 | CA | GROUP MEDICARE | OTHER |